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Applications Will Be Processed When Submitted ProperlyO'Sus <br /> p e%pE�urx 1vJ1I 'U`,__­_,­ <br /> APPLICAT �� <br /> FOR q'riCE USE: 1979 <br /> (For Non-Transferable, Revoc -dab ) 7 pUMP&WALL <br /> ENVIRONMENTAL HEALTH PERMIT] <br /> WATER QUALITY SAN JOAQUIN LOCAL <br /> (COMPLETE 4N TRIPLICATE) erein described.This application is <br /> Application is hereby made to the San Joaquin Local Health District for permit constrtic�Ir�lc r�r{st��t ll�� pp <br /> made in compliance with San Joaquin County Ordinance No. 1882 and the rules and regulations of the San Joaquin Local jiealthsDistrict. <br /> Q + City/Town ArJ <br /> Exact Site Address y �� <br /> Phone <br /> Owner's Name � <br /> � City <br /> Address s�. - S~G <br /> Contractor's Name Al�'A License# �.�� Business Phone 5 <br /> ` ~ Emergency P one " S <br /> Contractor's Address No <br /> Is Certificate of Workman's Compensation Insurance on Fike With SJLHD? Yes n <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ �+ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION 15- PUMP REPAIR❑ i <br /> REPLACEMENT <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> �r <br /> Sewage Disposal Field Cesspool/Seepage Pit Other. <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL_ ❑ OTHER Other Information ._f <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor TI <br /> H.P. <br /> Type of Pump <br /> PUMP REPLACEMENT: State Work Done <br /> PUMP REPAIR: <br /> ❑ State Work Done s <br /> r` <br /> DESTRUCTION OF WELL: <br /> Well Diameter Approximate Depth IC7 <br /> Describe Material and Procedure <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit <br /> is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." <br /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will call for a Grout I spe tion prior to grouting and a final inspection. — <br /> Signed X <br /> Title: Date: <br /> (Draw Plot Plan on Reverse Ide) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I Date <br /> Application Accepted By <br /> Additional Comments: <br /> Phase II Grout Inspection ��Illnaection <br /> inspection ByDate Inspection ByDate <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By JL;ly 31 <br /> REMIEASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> o ['7 <br /> Received by <br /> Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT--RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Eo:2009 STOCKTON,CA 9520 <br />